Improving Quality and Performance - Brandeis University

Improving Quality and Performance:

Cultural Competence and Workforce Diversity Strategies

January 2016

Introduction

The healthcare business landscape is changing. In the wake of the

Patient Protection and Affordable Care Act (ACA), newly insured

individuals are seeking health care outside of the emergency

department setting, bringing an increasingly diverse patient population

into the healthcare system. Newer payment models, including valuebased purchasing and pay-for-performance programs, create new

imperatives for hospitals and healthcare systems to contain costs while

improving patient outcomes and ensuring the quality of care for all

populations.

The increased emphasis on quality and cost-containment means that

many healthcare organizations are seeking to develop and implement

innovative approaches to service that incorporate new performance

measures. With guidance, more healthcare organizations can expand

upon their progress in this area, improving healthcare services, quality,

and health outcomes, while having broad community impact.

The Bottom Line

Improved staff retention, increased

market share, and reduced medical

liability expenses are tangible returns on

investments in organizational strategies

that increase workforce cultural

competence and diversity.1

Hospitals and healthcare systems that

understand their patient populations

and make quality improvements across

all demographic groups will improve

overall performance.2

Increasing the diversity of the healthcare

workforce improves patient satisfaction,

A key area of focus for these hospitals and healthcare systems is

healthcare utilization patterns, and

organization-wide cultural competence and workforce diversity, or

access to care for minority patients.3-5

cultural effectiveness. Achieving cultural effectiveness is predicated

upon successfully targeting seven elements ¨C leadership, institutional

Cohen, E., & Goode, T. (1999). Rationale for cultural

policies and procedures, data collection, community engagement,

competence in primary care (Policy Brief No. 1).

Washington, D.C.: National Center for Cultural Competence,

language and communication access, staff cultural competence,

Georgetown University.

1

and workforce diversity and inclusion. Research demonstrates that

Mayberry, R., Nicewander, D., Qin, H., & Ballard, D. (2006).

Improving quality and reducing inequities: A challenge

management practices and administrative policies designed to build

in achieving best care. Baylor University Medical Center

a culturally effective organization can improve patient and employee

Proceedings, (19)2, 103-118.

LaVeist, T., & Nuru-Jeter, A. (2002). Is doctor-patient race

satisfaction, the quality of clinical care delivered, and patient health

concordance associated with greater satisfaction with care?

2

outcomes. High performance in the areas of staff cultural competence

Journal of Health and Social Behavior, (43)3, 296-306.

and workforce diversity can result in an enhanced bottom line resulting

Hampers L., Cha S, Gutglass D., Binns H., & Krug S. (1999).

Language

barriers and resource utilization in a pediatric

from patient satisfaction-based performance incentives. Increased

emergency department. Pediatrics, 103(6 Part 1), 1253-1256.

workforce diversity and cultural competence can also lower costs

Mitchell, D., & Lassiter, S. (2006). Addressing health care

disparities and increasing workforce diversity: The next

as a result of increased employee retention, more efficient use of

step for the dental, medical, and public health professions.

interpreter services, and a reduction in unnecessary care and avoidable

American Journal of Public Health, (96)12, 2093-2097.

readmissions that can follow when communication and cultural

understanding improve.3 For these reasons, it is just as important to

understand the needs of the various racial and ethnic groups that

contribute to the rapidly increasing diversity in an organization¡¯s catchment area as it is to understand the differing needs

of the baby boomer and millennial market segments to which organization are trying to respond.

1

2

3

4

5

Although all seven elements contribute to success in becoming a culturally effective organization, this brief focuses

on specific indicators and approaches that tie service, quality, and outcomes to the implementation of organizational

strategies to improve workforce diversity and cultural competence. In addition to providing an overview of research in

the field, the brief includes case studies and resources to facilitate the creation of a strategic plan.

Healthcare Disparities Increase Costs ¨C Culturally Effective Organizational Practices Increase Value

Healthcare disparities raise the overall cost of health care. If not actively addressed, a significant area of potential

cost-savings will remain unchanged, impacting the healthcare system and broadly impacting community health.

For example, minority women in New Hampshire are three times as likely as non-Hispanic Caucasian women to

be diagnosed with cardiovascular disease.4 The cancer-related death rate in New Hampshire is almost twice as high

for non-Hispanic Black women as it is for Caucasian women: 294 per 100,000 non-Hispanic Black women and

150 per 100,000 Caucasian women.5 To address variation in treatment and outcomes, government, private payers,

and healthcare accrediting bodies are emphasizing the importance of cultural effectiveness.6 Culturally effective

organizations enable, cultivate, and support the delivery of high-quality health care for all groups of people.7 Work in

this area is already underway to address gaps in health equity in New Hampshire.8

Research shows that employing a workforce that reflects the cultural, ethnic, and linguistic diversity of the

community an organization serves, while simultaneously achieving cultural competence benchmarks, can

have multiple benefits. These benefits can include a reduction in average inpatient length of stay and avoidable

readmissions, an increase in treatment adherence, improved patient satisfaction ratings, more appropriate service

utilization patterns, and enhanced operating efficiencies.9 Thus, workforce diversity and cultural competence

strategies can play an important role in organizational efforts to improve financial results and enhance services for an

increasingly diverse population.

Documented Cost-Savings

The Case for Change

Healthcare organizations that have diversified their

workforce and enhanced their cultural effectiveness report

numerous beneficial outcomes for patients and for the

businesses themselves. There likely are additional benefits

that have not been reported publicly, as these efforts are

works-in-progress. Research on the impact of workforce

diversity and cultural competence has found that:

Service Utilization

? Decreased inappropriate utilization1

? Shortened length of stay1

? Increased utilization of profitable services1

? Expanded total number of patients1

?

Healthcare workforce diversity affects patient health

outcomes, treatment adherence, safety, satisfaction, and

quality of care.10

?

Workforce diversity is associated with improved patientprovider communication.11

Staff Productivity

? Improved discharge capacity1

? Enhanced overall productivity1

?

Racial and ethnic concordance in patient-provider

relationships can increase patient engagement.12

?

Patients with limited English-speaking abilities have

better health outcomes, receive higher quality care, and

report higher satisfaction when they have access to trained

professional interpreters and bilingual/multilingual staff

members.13

Meeting Joint Commission Standards

? Serve patients¡¯ communication needs2

? Accommodate patients¡¯ cultural and

ethnic needs2

?

2

Language Interpretation

? Lower contract interpreter costs1

? Reduced communication delays between

providers and patients1

? Reduced system inefficiencies (e.g., wait

time for interpreters)1

Organizations that possess greater levels of cultural

competence earn higher scores on the Hospital Consumer

Assessment of Healthcare Providers and Systems

(HCAHPS) survey in the areas of communication, effective

pain control, and staff responsiveness.14

Cobb, A.J. (2007). Making the business case for culturally

and linguistically appropriate services in health care:

Case studies from the field. Washington, D.C.: Alliance of

Community Health Plans Foundation. Retrieved from http://

minorityhealth.Assets/pdf/Checked/CLAS.pdf

2

The Joint Commission. (2014). A Crosswalk of the National

Standards for Culturally and Linguistically Appropriate

Services (CLAS) in health and health care to The Joint

Commission Hospital Accreditation Standards. Retrieved

from

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Definitions

Culturally Effective Organization

An organization with leadership

that formally acknowledges the

importance of organizational

cultural competence through policysetting, organization-wide training,

performance monitoring, data

collection, patient communication,

care delivery that is sensitive to

diverse needs, targeted human

resources strategies, and community

engagement.15

Cultural Competence

A set of attitudes, skills, behaviors,

and policies that enable staff

members to work effectively in crosscultural situations.16

Workforce Diversity:

A workforce composed of a range of

diverse employees (by culture, race/

ethnicity, language, etc.) represented

at all levels of the organization.i

Workforce Inclusion

Creating an accepting environment

where differences are honored, all

employees feel valued and respected,

and where staff members have the

confidence to do their best work.17

Racial and Ethnic

Healthcare Disparities

¡°Racial or ethnic differences in

the quality of health care that are

not due to access-related factors

or clinical needs, preferences, [or]

appropriateness of intervention.¡±18

Examples of Performance Measures

Clinical Measures Disaggregated by Race/Ethnicity & Language Status

? Ambulatory care-sensitive readmissions1

? Avoidable emergency room visits2

? Length of stay measured in hours2

? Inappropriate test ordering2

? Sentinel disparity indicators (e.g., pain management in the emergency

department)3

? HEDIS outcome measures

Patient & Employee Satisfaction Disaggregated by Race/Ethnicity &

Language Status

? Patient satisfaction scores4

? Number of patient complaints

? Diverse employee satisfaction scores5

? Employee discrimination complaints5

Cultural Competence

? Pre/post staff cultural competence training knowledge assessment scores

? Chart review documenting clinician behavior change6

? Patient experience questions disaggregated by race, ethnicity, and language

Operations

? Waiting time for new clinical appointments for those requiring interpreters7

? Cost of contract interpretation services1

? Number of in-person vs. telephone interpreter contacts1

Human Resources Disaggregated by Race/Ethnicity

? Staff hiring, retention, and advancement rates

? Staff absenteeism

? Demographic composition of senior leadership and board of directors8

? Proportion of diverse employees at each job level9

Cobb, A.J. (2007). Making the business case for culturally and linguistically appropriate services in health

care: Case studies from the field. Washington, D.C.: Alliance of Community Health Plans Foundation.

Retrieved from

2

Betancourt, J. (2006). Improving quality and achieving equity: The role of cultural competence in

reducing racial and ethnic disparities in health care. Retrieved from

3

Thorlby, R., Jorgensen, S., Seigel, B., & Ayanian, J. (2011). How health care organizations are using data on

patients¡¯ race and ethnicity to improve quality of care. The Milbank Quarterly, 89(2), 226-255.

4

Health Research & Educational Trust. (2013). Becoming a culturally competent health care organization.

Retrieved from

5

Brenman, M. (2012, November 24). Diversity metrics, measurement, and evaluation. Retrieved from



6

Betancourt, J., & Green, A. (2010). Linking cultural competence training to improved health outcomes:

Perspectives from the field [Commentary]. Academic Medicine, 85(4), 583.

7

U.S. Department of Health and Human Services, Health Resources and Services Administration. (2001).

Cultural competence works: Using cultural competence to improve the quality of health care for diverse

populations and add value to managed care arrangements. Retrieved from

8

American Hospital Association. (2004). Strategies for leadership: Does your hospital reflect the

community it serves?: A diversity and cultural proficiency assessment tool for leaders. Retrieved from



9

Gallagher-Louisy, C. (2013, July). The ROI of D&I: Why municipalities must measure their efforts

in equity, diversity and inclusion. Retrieved from

mw-roi/

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In this document, use of the term ¡°diversity¡± is limited to racial, ethnic, and linguistic diversity. However, creating a culturally effective organization

requires attention to all aspects of diversity, including age, gender and sexuality, physical and mental disabilities, religion, etc.

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Measuring Success

A wide variety of resources and tools are available for those looking to measure the success of their workforce diversity

and/or cultural competence strategies. In addition to consultancies that specialize in advising organizations on such

assessments, printed and electronic tools are available for those who choose to assess their outcomes independently

(see Resources). Some of these tools also may be useful for assessing organizational readiness in the period leading up

to accreditation visits, or in assessing progress toward meeting Enhanced National CLAS Standards.19 For example,

users of a cultural competence assessment tool created by The Lewin Group indicated that the instrument was helpful

in preparing the organization for a Joint Commission accreditation visit.20

Measuring progress within both the inpatient and outpatient environments can provide the organization¡¯s leadership

with rich data that may highlight a need for broader strategies or validate the wide-reaching success of current work.

This can be approached by measuring smaller organizational units. For example, organizations may measure and make

comparisons across departments and hospital-affiliated practices.21 The following table provides additional examples of

useful approaches to the assessment process.

Select Evaluation Research Options

Type of Assessment

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Unit of Measure

Possible Measures

Primary Audience

Patient satisfaction

Individual

Number of patient and family complaints, satisfaction with quality of care received, self-reported patient understanding of discharge

instructions, and satisfaction with interpreter

services (if used)

Leadership, clinical staff, Patient and

Family Advisory Council (PFAC),

and community leaders

Patient and staff

demographics

Individual

Patient and staff member race, gender, age,

primary language, etc.

Leadership, clinical staff, and human

resources

Patient health

outcomes (to

identify treatment

variation)

Individual

Quantitative clinical health outcomes

(e.g., post-visit BP or A1c, mortality rates,

nosocomial infection rates) and patient-reported outcomes (e.g., incidence of difficulty

performing ADL)

Leadership and clinical staff

Community needs

Catchment area

Environmental scan of services already in

existence, analysis of services needed, trends

in community demographics, etc.

Leadership, PFAC, and community

leaders

Operations

Organization

Cultural appropriateness of meal selections,

signage, patient education materials, and

legal documents (both complexity and

language interpretation)

Leadership, PFAC, and legal counsel

Staff cultural

competence

Organization

and individual

Knowledge, attitude change, and evidence of

behavior change (e.g., documented through

clinical chart review)

Leadership, human resources, and

community leaders

Staffing

Organization

Staff diversity, retention rates, and grievance

rates disaggregated by race/ethnicity and

primary language

Leadership and human resources

Key Lessons from the Field and the Literature

Healthcare organizations that implement and evaluate cultural competence and workforce diversity strategies learn

important lessons along the way. Some have found that engaging ¡°linguistically appropriate services¡± is the best first

step toward cultural effectiveness.22 Focused attention on the professional development of bilingual and multilingual

employees has been key to many organizations that have achieved cultural effectiveness.23

Performance assessment during and after the implementation of cultural competence and workforce diversity

interventions should be part of any planned effort.24 It is essential to strive to collect high-quality data. High-quality

data helps ensure the rigor and usefulness of performance assessments intended to measure success. Through

interviews with key researchers in the field, as well as a review of the literature, the authors have identified both dataspecific lessons, as well as general lessons, that are applicable to most healthcare organizations that seek to move

forward with their cultural effectiveness work.

Conceptualize the Performance Assessment

Develop a common understanding of how the organization defines cultural competence, workforce diversity and

inclusion, and disparity.

? Identify the organizational level that the intervention is designed to impact: a) the entire organization, b) a single

department or sub-group, or c) individuals involved directly or indirectly with care delivery.

? Delineate specific desired changes, such as clinical process, clinical outcomes, employee behavior change, reduction

in adverse health events, return on investment, etc.

? Determine which process and/or outcome variables would best measure the desired changes.

? Design an intervention drawing on existing evidence linking cause and effect for the challenge being addressed.

? Include culturally and linguistically diverse staff and/or external stakeholders in the planning and implementation of

the intervention.

?

Ensure Quality of Data

Collect baseline data to compare to future data collection periods.

Consider whether there will be enough data to generate statistically significant results. If samples are small, consider

combining data collected during a longer time period.

? Make use of qualitative methods (e.g., interviews and focus groups) to help explain quantitative findings from

surveys, etc.

? Use direct measures of minority patient experience on patient surveys (e.g., measures of patients¡¯ perceptions of staff

cultural sensitivity, respect, and discrimination).

? Disaggregate the data by race, ethnicity, and language during analysis to determine whether different outcomes exist

for diverse groups.

?

?

Facilitate Data Collection and Access

Update race, ethnicity, language, and contact information on an ongoing basis when patients go through the

registration process to save time and money, as well as to facilitate the sampling process that occurs before an

internal assessment.

? Use multiple methods of data collection when gathering feedback from diverse patients to ensure their ability to

participate if facing language or other barriers (e.g., focus groups offered in languages other than English).

? Provide patients with easy-to-understand materials in multiple languages and use interpreters to ensure

communication access and full patient participation in assessments.

? Ensure that patient race, ethnicity, and language information is shared across the organization and available to all

staff who have access to patient records (e.g., clinical, billing, etc.).

?

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